Housing First Research Articles

Results of a Process Evaluation of the Implementation of a Housing First Program in Waterloo, Canada

This study evaluated PATHS2Home (P2H), a Housing First program in Canada, through qualitative interviews and focus groups with 34 program staff, participants, and partners. Results showed successful implementation with participant satisfaction, strong program design and leadership, skilled staff, positive service system relationships, effective housing support, and fidelity to the Housing First (HF) model. Challenges included skepticism of the program model, communication with partners, staff turnover, and systemic factors such as affordable housing availability. Overall, the evaluation showed successful implementation of the P2H program in line with HF principles and identified several areas for improvement to better support participants and achieve program goals.

Females and Housing First: An analysis of 18-month outcomes in a randomized controlled trial.

The main objective of this research was to qualitatively examine the impacts of Housing First (HF) specifically on those participants who identified themselves as female in response to question asking what their gender was. The data analyzed are from a larger, muti-site, randomized controlled trial. χ2 analysis was used to compare the life changes (coded as positive, neutral, or negative) experienced by 64 females (42 HF and 22 TAU). An in-depth qualitative analysis was conducted on 45 of these participants (23 HF and 22 TAU). Significantly more female HF participants reported making positive life changes from baseline to 18-month than those in TAU. Relative to females in TAU, female HF participants reported a number of specific positive changes, including enhanced safety, improved recovery in mental illness, greater reductions in drug use, and individual changes. The implications of findings for strengthening HF programs to meet the unique needs of female participants are discussed.

Five-Year Post-Housing Outcomes for a Housing First Cohort in Aotearoa, New Zealand

This paper presents outcomes for a Housing First (HF) cohort in Aotearoa, New Zealand. Using integrated governmental administrative data, we analysed outcomes for a cohort of 357 people, comparing health, justice, income, and social welfare indicators the year prior to HF and five years after being housed. In the fifth year after being housed, improved outcomes across each of these sectors were noted, with particularly impressive improvements found in income levels (+38%) and mental health. These results demonstrate the efficacy of this HF programme in improving well-being. Despite such notable improvements, there is room for HF to have a greater impact in the context of wider system changes that support overall well-being, as well as the goal of making homelessness rare, brief, and non-recurring.

Distal supports, capabilities, and growth-focused recovery: A comparison of Housing First and the staircase continuum of care.

Adults who have substantial histories of homelessness and complex support needs may feel ambivalent about integrating into their communities and find it difficult to do so. Being familiar to and recognized by others as a resident in a neighborhood or community are sources of "distal support"that provide individuals with feelings of belonging to their community and are important to recovery from homelessness. We hypothesized that individuals engaged with Housing First (HF) programs would report more distal support than individuals engaged with traditional homeless services (treatment as usual, TAU), and that distal support would predict more community integration, growth-related recovery, and achieved capabilities. We analyzed data collected from homeless services users (n = 445) engaged with either HF or TAU in eight European countries. Measures included achieved capabilities, growth-focused recovery, distal supports, and community integration. Serial mediation analyses confirmed our hypothesis that the effects of HF on growth-related recovery and achieved capabilities are indirect, mediated by distal supports and community integration. Findings are discussed in relation to the importance of modeling the effects of HF on social and psychological outcomes as indirect and identifying important mediators that translate the effects of HF components on social and psychological outcomes. We also note the importance of case management activities that encourage clients to develop and sustain distal supports with others who live and work in their neighborhoods.

A Qualitative Exploration of People Who Have Left Housing First and Returned to Homelessness

This article offers a thick, rich, multidimensional, and situational look into a Housing First (HF) program in Charlotte, North Carolina, called HousingWorks. This study focuses on individuals who have experienced chronic homelessness and who exited permanent supportive housing (PSH) programs that employ a HF model and return to homelessness. In January 2022, there were 582,500 people experiencing homelessness in the United States (The U.S Department of Housing and Urban Development [HUD], 2023). One-third of these individuals had patterns of chronic homelessness, which has doubled since 2016 (HUD, 2023). Additionally, one-third of unsheltered individuals are at a high risk of being unsheltered again. To address issues of chronic homelessness, emphasis has been placed on increasing supportive housing, which combines permanent affordable housing with supportive services (permanent supportive housing), commonly called a housing first, or the rapid rehousing approach. Participants exited HousingWorks for multiple individual and programmatic reasons. All exits in this study were tied to relationships individuals had with friends, family (of choice and biological), romantic partners, case managers, and neighbors. Consumers, providers, and former residents describe their experiences and offer insights for improving housing retention in PSH programs. Implications for implementation and housing first fidelity criteria are also discussed.

How Do Housing First Caseworkers Mediate Landlord-Tenant Conflicts?

ABSTRACT Housing First (HF) is a service model that addresses chronic homelessness with permanent supportive housing. Previous studies have analysed market constraints on housing searches, strategies caseworkers use to navigate these barriers, and clinical interventions that help clients transition to unsupported housing. Little research has examined the nuanced ways caseworkers mediate landlord-tenant conflicts once a lease has been formed. I advance those studies by answering the question: How do HF caseworkers mediate landlord-tenant conflicts? Using interview and focus group data collected in a large U.S. County, I provide evidence that HF caseworkers mediate landlord-tenant conflicts by managing “enforcement costs” throughout the lease. Enforcement costs are (non-)financial expenditures beyond the price of a commodity to ensure co-signers honour their contractual obligations. HF caseworkers manage enforcement costs by absorbing them for landlords and/or tenants throughout the lease. When caseworkers cannot or will not absorb enforcement costs, they are keen to delegate this responsibility to other parties. Absorption and delegation can help rebalance power inequities and/or undermine the reputation of HF programmes.

Youth, Crime, and the Potential Cost Offset to Housing First Programs

Housing First (HF) is an approach that emphasizes providing housing as a precondition for assisting people experiencing homelessness. To the extent that housing reduces contacts with police, HF may reduce criminal behaviour and so reduce costs borne by the justice system. This may be particularly true for youth whose homelessness often forces them to adopt survival behaviour that exposes them to police and bylaw enforcement officers. Using regression analysis, we employ linked administrative data sets from police and from HF programs to examine how interactions of youth with police change following admission to a HF program. An important contribution of our study is the use of administrative police records rather than self-reported data on the number of criminal incidents and their severity. Unconditional quantile regression is used to observe HF’s effect on changes in both the number and severity of criminal incidents. Controlling for demographic characteristics of youth and for type of housing program and using administrative police records as opposed to self-reported police interactions, we find only weak evidence to suggest that the number of criminal incidents falls following admission to a HF program and only weak evidence of a fall in the seriousness of crimes.

Homeless people's recovery in Housing First and Traditional Services: The role of working alliance in Italian housing services.

This study aims to investigate whether a working alliance could represent a potential mechanism that explains the effectiveness of housing services in terms of user recovery, comparing the Housing First (HF) model with Traditional Services (TS). This study included 59 homeless service users in Italy (29 = HF; 30 = TS). Recovery was assessed upon entering the study (T0) and after 10 months (T1). Results indicate that participants inserted in HF services were more likely to report stronger working alliances with social service providers at T0 that, in turn, was directly associated with higher levels of users' recovery at the beginning of the study and indirectly (through recovery at T0) with recovery at T1. Implications of the results are discussed with respect to research and practice on homeless services.

Narratives of people with serious mental illness in Housing First: a qualitative analysis of factors contributing to housing instability and housing stability

ABSTRACT There has been little previous research that has examined factors related to housing stability and instability among Housing First (HF) tenants. Qualitative research was used to determine themes related to housing stability and instability for people with mental illness participating in a HF program implemented in five Canadian cities. Data were gathered for all participants who completed qualitative interviews at baseline and an 18-month follow-up. At the 18-month follow-up interviews, those who were stably housed (n = 110) were significantly more likely to report positive life changes than those who were unstably housed (n = 75). Among a sub-sample of these participants, in-depth narratives were compared for stably housed (n = 25) and unstably housed (n = 21) tenants. Challenges to achieving housing stability included substance use and continued exposure to substance-using networks, evictions/multiple housing losses, incarceration and/or involvement with the legal system, and neighborhood location of housing. Themes promoting housing stability were having positive relationships with the HF program staff and program, achieving greater community integration, and making progress towards recovery. Recommendations for promoting housing stability were provided.

Predictors of housing instability and stability among Housing First participants: A 24-month study

ABSTRACT This study examined the characteristics of people who experienced housing instability and stability after 24 months of being enrolled in Housing First (HF). A companion study addresses the same objective using qualitative methods. A sequential logistic regression was conducted to determine predictors of unstable and stable housing at 24 months of enrollment in HF in a randomized trial. We applied the Gelberg-Andersen. Behavioral Model for Vulnerable Populations to identify and group predictor variables. Thirty-one percent of the HF participants (N = 302/977) met the study criteria for housing instability (i.e. stably housed for less than 90% of last six months). Residence in Winnipeg, longer accumulated lifetime homelessness, and higher levels of substance use predicted unstable housing. Residence in Toronto and Montreal, older age, being in an ethno-racial minority group (other than Indigenous), higher income, higher perceived housing quality, and having a family physician predicted stable housing. The findings of the study have implications for strengthening HF supports to better address the needs of HF participants who may be at risk of housing instability.

Providing Housing First services for an underserved population during the early wave of the COVID-19 pandemic: A qualitative study.

We assessed the critical role of Housing First (HF) programs and frontline workers in responding to challenges faced during the first wave of the COVID-19 pandemic. Semi-structured interviews were conducted with nine HF frontline workers from three HF programs between May 2020 and July 2020, in Toronto, Canada. Information was collected on challenges and adjustments needed to provide services to HF clients (people experiencing homelessness and mental disorders). We applied the Analytical Framework method and thematic analysis to our data. Inability to provide in-person support and socializing activities, barriers to appropriate mental health assessments, and limited virtual communication due to clients' lack of access to digital devices were among the most salient challenges that HF frontline workers reported during the COVID-19 pandemic. Implementing virtual support services, provision of urgent in-office or in-field support, distributing food aid, connecting clients with online healthcare services, increasing harm reduction education and referral, and meeting urgent housing needs were some of the strategies implemented by HF frontline workers to support the complex needs of their clients during the pandemic. HF frontline workers experienced workload burden, job insecurity and mental health problems (e.g. distress, worry, anxiety) as a consequence of their services during the first wave of the COVID-19 pandemic. Despite the several work-, programming- and structural-related challenges experienced by HF frontline workers when responding to the needs of their clients during the first wave of the COVID-19 pandemic, they played a critical role in meeting the communication, food, housing and health needs of their clients during the pandemic, even when it negatively affected their well-being. A more coordinated, integrated, innovative, sustainable, effective and well-funded support response is required to meet the intersecting and complex social, housing, health and financial needs of underserved and socio-economically excluded groups during and beyond health emergencies.

Differential impacts of COVID-19 and associated responses on the health, social well-being and food security of users of supportive social and health programs during the COVID-19 pandemic: A qualitative study.

The effects of the coronavirus disease‐2019 (COVID‐19) pandemic on the lives of underserved populations are underexplored. This study aimed to identify the impacts of the COVID‐19 pandemic and associated public health responses on the health and social well‐being, and food security of users of Housing First (HF) services in Toronto (Canada) during the first wave of the COVID‐19 pandemic. This qualitative descriptive study was conducted from July to October 2020 in a subsample of 20 adults with a history of homelessness and serious mental disorders who were receiving HF services in Toronto. A semi‐structured interview guide was used to collect narrative data regarding health and social well‐being, food security and access to health, social and preventive services. A thematic analysis framework guided analyses and interpretation of the data. The COVID‐19 pandemic and response measures had a variable impact on the health, social well‐being and food security of participants. Around 40% of participants were minimally impacted by the COVID‐19 pandemic. Conversely, among the remaining participants (impacted group), some experienced onset of new mental health problems (anxiety, stress, paranoia) or exacerbation of pre‐existing mental disorders (depression, post‐traumatic stress disorder and obsessive‐compulsive disorder). They also struggled with isolation and loneliness and had limited leisure activities and access to food goods. The pandemic also contributed to disparities in accessing and receiving healthcare services and treatment continuity for non‐COVID‐19 health issues for the negatively impacted participants. Overall, most participants were able to adhere to COVID‐19 public health measures and get reliable information on COVID‐19 preventive measures facilitated by having access to the phone, internet and media devices and services. In conclusion, the COVID‐19 pandemic and associated response measures impacted the health, social well‐being, leisure and food security of people with experiences of homelessness and mental disorders who use supportive social and housing services in diverse ways.

Health and social outcomes in the Housing First model: Testing the theory of change

SummaryBackgroundHomelessness continues to grow globally. The Housing First (HF) model offers immediate access to housing and support services without preconditions and has a growing body of evidence documenting its effectiveness at ending homelessness. HF has a robust theory of change that hypothesizes how unique program components (i.e., immediate access to housing, separation of services from housing, client choice, etc.) drive positive social and health changes over time. We advance the understanding of how HF causes client improvement by empirically testing this program's theory of change.MethodsUsing a unique longitudinal quantitative data from the large Canadian At Home/Chez Soi Housing First trial we used path analysis to test the theory of change for Quality of Life, Crisis related events or service utilization, and Recovery. Program pathways and health and social outcomes were measured at enrolment, 6-, 12- and 24-months post-enrolment.FindingsMost hypothesized pathways were confirmed with path analysis. Confirmed pathways for two outcomes– Quality of Life (QOL) and Recovery – were similar. Health and social consultations at enrolment, health status at 6- and 12-months post enrolment, and social connectedness at 12-months were important predictors of the 24-month outcomes of Quality of Life and Recovery, but not for Crisis related events or service utilization.InterpretationThis analysis directly responds to recent calls for more empirical evidence about intervention mechanisms. Ensuring linkages to health and social service consultations for clients, supporting clients’ engagement with family and community, and enabling clients to improve or maintain good health will drive better longer term client outcomes within Housing First.FundingFunding Mental Health Commission of Canada.

Impact of Housing First on Psychiatric Symptoms, Substance Use, and Everyday Life Skills Among People Experiencing Homelessness.

The current unblinded, randomized controlled trial analyzed psychiatric symptoms, substance use, and life skills outcomes in participants after 21 months in the Housing First (HF) program. The HF group (intervention) comprised 46 participants and the treatment-as-usual (TAU) group (control) comprised 41 participants. Quantitative outcome measures were collected at baseline and 8 and 21 months. Primary outcomes were mental health and substance use. Secondary outcomes were everyday life skills. Descriptive and comparative analyses and linear regression models are presented. At 21 months, the HF group presented significantly better outcomes regarding alcohol and cannabis use than the TAU group. Moreover, the subgroup of HF participants with severe mental illness had significant improvements in psychotic symptoms, anxiety, depression, social relations, and cannabis use compared to TAU participants. [Journal of Psychosocial Nursing and Mental Health Services, 60(9), 46-55.].

Working with People Experiencing Homelessness in Europe

ABSTRACT In Europe, the widespread transition from the Traditional Staircase (TS) model to the Housing First (HF) model is transforming the way social service providers work with people experiencing homelessness. This study examined social service providers’ perspectives in both models regarding factors that facilitate or hinder their work. Data were collected through 17 photovoice projects involving 81 social service providers from eight European countries. The results show factors affecting social service providers’ work at three levels: systemic, organizational, and individual. Professionals in TS and HF identified similar topics; however, TS providers discussed more obstacles to work. Implications for practice are discussed.

Implementation structures at work. Exploring implementation and de‐implementation attempts regarding Housing First and Individual Placement and Support

AbstractResearch shows that resistance to change might occur in organisations that implement new evidence‐based practices (EBP). Formal and informal structures may work to retain traditional interventions, potentially counteracting the implementation process. Little is known about the de‐implementation of traditional practices to leave room for and enhance the implementation of EBPs. This study uses implementation structures as a theoretical framework with the aim of analysing implementation and de‐implementation factors among Swedish municipalities that provide support to vulnerable clients through the Housing First (HF) or Individual Placement and Support (IPS) interventional programmes. This cross‐sectional study is based on a digital survey and collects descriptive and qualitative data from three organisational levels in each responding municipality in Sweden. The descriptive statistics and qualitative texts were analysed using content analysis. The results show the incidence of HF and IPS, if and to what extent the interventions are going to be developed further, and partially, describe the organisational settings of HF and IPS. Organisational factors shown to have a negative impact on the implementation of HF and IPS were identified. The mapping of professional experiences from the intersection between HF or IPS and organisations such as the Swedish Health Insurance Office, the social services, and other similar welfare organisations, indicates that the realisation of HF and IPS requires expanded collaboration, which raises the consideration as to whether it is necessary to de‐implement broader frameworks and guidelines in these organisations to provide the prerequisites that enable the implementation of EBPs.

The impact of Housing First participation on police-reported crime and crime severity

ABSTRACT Housing First (HF) addresses chronic homelessness by admitting individuals into permanent shelter regardless of their situation. Studies using self-reported data suggest that HF can potentially decrease justice system use, but they are limited by inaccurate measurement of police contacts. This study uses administrative data from police to measure the change in number of police interactions, change in average crime weight (or importance of crime), and change in the distribution of crime weight, before and after HF. Six hundred and two chronically homeless individuals with a history of criminal involvement and who were accommodated by an HF shelter between three months to a year were eligible for this study. We use unconditional quantile regression to observe HF’s effect on changes in the distribution of crime weights over time. While the average crime weight increased during the study period (57–79.1), the average number of police interactions decreased. Statistically significant decreases of approximately 5 crime weight units were observed between percentiles 0.54 and 0.65 and decreases of approximately 15 crime weight units occurred at percentiles 0.73 and 0.81. HF is effective at reducing minor crimes at the highest end of the distribution and helping those experiencing homelessness to avoid the warrant cycle.

Stakeholder perspectives on sustainment of Housing First in a VA permanent supportive housing program.

To evaluate the sustainment of Housing First (HF) implementation in a permanent supportive housing program for homeless-experienced veterans, 5 years after practice implementation. From 2016 to 2017, primary data were collected from providers and veterans in the Department of Housing and Urban Development-VA Supportive Housing (HUD-VASH) program at Los Angeles. Guided by the integrated sustainability framework, we performed a mixed-methods study to evaluate the sustainment of HF, an evidence-based practice implemented to improve housing outcomes. To assess sustainment, we measured fidelity to HF in six of seven HUD-VASH teams. These data were integrated with qualitative interviews with providers and veterans who described perceived sustainment to HF and contextual factors that supported or impeded sustainment. Fidelity to HF at 5 years after practice implementation, as a proxy for sustainment, was quantified via surveys with HUD-VASH teams. HUD-VASH providers (n=51) and 31 veterans participated in semi-structured interviews. Team-based template analyses were used to develop an emergent understanding of stakeholder perspectives on HF sustainment. Overall, HUD-VASH teams reported HF sustainment. The lowest fidelity scores were found in the domains of client-to-staff ratios, frequency of client-provider contact, and time to housing. Qualitative findings indicated that outer contextual factors (e.g., housing scarcity) and organizational factors (e.g., staff turnover) impacted HF sustainment. Providers identified changes in leadership and unmet resource needs as impediments to practice sustainment. All stakeholders identified positively with the HF practice and believed that the approach benefited veterans. This snapshot of HF sustainment demonstrates that this practice can be sustained over time. However, strong leadership, organizational resources, and community partnerships are needed. Adaptations to HF in response to outer contextual factors and organizational capacity may result in practice sustainment while allowing for flexibility in service provision.

Being homeless at the "End" of homelessness navigating the symbolic and social boundaries of housing first.

Housing First (HF) has emerged as the dominant paradigm in homelessness policy and has been praised for bringing an "end" to the homelessness crisis. Others claim, however, that HF facilitates further sociospatial exclusion of people experiencing homelessness (PEH). To advance this debate and understand HF within its larger sociological context, this article examines how HF policies translate to the lived experiences of those who remain in shelters and on the streets. Through interviews with 22 PEH, we demonstrate how HF confronts PEH with a set of strategic dilemmas that we frame using the concept of "boundary-work." First, PEH must negotiate the symbolic boundaries that HF establishes between "worthy" and "unworthy" for the purposes of distributing housing. Second, once housed, PEH face challenges in navigating the social boundaries that separate the private space of the dwelling, the transitional spaces of homelessness (e.g., streets, shelters), and the increasingly gentrified public spaces of the city. We end by discussing the implications of these findings for evaluating HF programs and demonstrating the value of a boundary-work perspective on homelessness.

Homemaking among the ‘chronically homeless’: a critical policy ethnography of Housing First

Housing First (HF) has become a prevalent public response to homelessness in North America and Europe. It supports individuals who have experienced long-term or ‘chronic’ homelessness in accessing independent housing without having to comply with addiction or mental health treatment. This article examines some of the challenges faced and expressed by HF program participants. Based on a critical policy ethnography of HF in two Canadian cities (Ottawa and Gatineau) and by drawing from a theoretical framework on meanings and feelings of home, it highlights how long term shelter users respond and adapt to housing with means of homemaking that challenge normative conceptions of ‘doing home’. Through fieldwork observations, the article describes how homeless shelters can represent ‘home-like’ sites and highlights a typology of homemaking, which reveals areas for policy improvement.